GP delivery key to alleviating hospital overcrowding, says Longford doctor

Dr Padraig McGarry highlights the current issues in our health system

A&E overcrowding persists at Tullamore Hospital

The terms `Trolly Crisis’ and `Hospital Overcrowding’ have become all too familiar of late and barely a week goes by without some headline in this regard to the extent that the public have almost become inured to the situation.

Hospital overcrowding and trolly crisis is a multi- layered and complex problem requiring a multidisciplinary response - the answers to which go beyond the scope of this article but I will try and distill down the most salient points.

Fact – we have a rapidly increasing population but, more importantly, an ageing population – with the over 65 year cohort increasing from 586,600 (2014) to 860,000 (2026) – an increase of 36% and set to continue, and in the over 80 cohort an estimated rise from 250,00 to 495,000 in the years 2016-2040.

In common with other advanced economies, Ireland is also experiencing a rise in the number of people living with a Chronic Disease – with over one million adults currently having either cardiovascular disease, diabetes or chronic respiratory disease – with a significant percentage having more than one disease.

This trend is expected to continue into the future.

At present, chronic diseases account for a significant proportion of hospital activity, including 40% admissions and 75% of hospital bed days.

The situation is compounded when one looks at the average number of inpatient and day case beds in the Irish public health system – Ireland has 276 beds/100,000 compared to the Western European average of 449 beds/100,000.

If private beds are included, this rises to 358 bed/100,000 – still well short of the required number.

There is clearly a serious bed capacity issue at play here resulting from the massive reduction in public hospital beds over the past eight years – entirely predictable.

To make matters worse, most of Ireland's hospitals are working at over 93.8% capacity – a dangerous situation, which affects patients' health.

The established safe occupancy threshold is 85% - once reaching 92.5% tipping point results in significantly higher patient mortality, due to rationing of resources and elevated stress levels.

It is estimated that Ireland needs an additional 3,500 inpatient beds to bring us to the Western European average.

Increasing hospital beds on its own will not solve the problem as there is a serious shortage in manpower in the hospital sector – with over 800 Hospital Consultant posts left unfilled. Research has shown that a Consultant Delivered hospital service is associated with:

*Marked reductions in all cause mortality following admission with acute coronary syndromes and a significant reduction in hospital length of stay.

*Improved patient outcomes and satisfaction and reduced length of stay in emergency care without increases in adverse events or readmissions compared to consultant care – led.

*A 96.9% appropriate response rate during the first review of a trauma case.

Unfortunately, the Irish Health Care system is no longer viewed as an employer of choice and many Consultants are choosing to go to other jurisdictions where their expertise is more appreciated and their working conditions more favourable.

This has led to the unprecedented number of unfilled consultant posts in Ireland - unthinkable in the past - which has a knock on effect that gives rise to serious capacity issues in hospitals resulting in overcrowding.

The shortage in medical staff is across many sectors and in particular there has been a significant exodus from hospitals of Irish trained nursing staff who, like their consultant colleagues, no longer view the Irish health system as the employer of choice – opting to move to other jurisdictions where terms and conditions are more favourable.

One of the solutions that has been suggested is to discharge patients from acute hospital beds to community and long term care – and certainly there is merit here.

While only a small percentage of elderly people require long term care, the ageing population will have a significant impact on the number of long stay beds required.

It has been predicted that, based on 2006 utilisation by 2020 demand for long term residential care, formal and informal homecare would increase by almost 60%.

There needs to be a significant increase in capacity for home care and long term care to address this need.

Indeed the mantra from almost every research group, from Slaintecare to the Government Capacity Review, is that the future and saviour of the Irish Health system lies in the provision of care in the community – translated into General Practice.

This has been known for the past 20 years and has been flagged by the Irish Medical Organisation ad nauseum.

Investment in General Practice would allow some of the current workload of hospitals to be carried out in General Practice including Chronic Disease Management delivered by General Practitioners and appropriate preventative medicine delivered by General Practitioners which would delay onset, and certainly contain and prevent progression of chronic diseases – thus reducing the necessity for hospital care.

That General Practitioners could deliver on this is without doubt, but this is prefaced on the presumption that such workload would be adequately resourced.

It has been shown that for every euro invested in General Practice by Government the result is a five fold saving across the health system – thus logic points in that direction.

The response of the past 10 years from successive governments has been to reduce, through FEMPI cuts, 38% of the resources afforded to GP practices to deliver this service - the very service it flagged as the appropriate vehicle to deliver reform of the health service as espoused by every expert group – it beggar's belief .

This has resulted in a major reduction in the ability of General Practice to absorb some of the overflow from hospitals; failure to deliver those items of service which currently are being carried out in hospitals but could be done in GP surgeries; failure to be able expand its workforce to assist in the transfer of patients to community hospitals or community settings; but more significantly and which will have profound implications in the future, an ageing workforce that is hastening towards the exit doors of retirement, with 666 GPs estimated to retire in the next seven years and newly trained GPs opting to delay at the very least, and in many cases opting for other jurisdictions for similar reasons as their consultant and nursing colleagues.
This will result in a further erosion of the capacity in the health system, and with the spectre of many areas being unable to attract a GP - in particular rural and deprived areas.

This will result, as is currently evolving in certain areas, a further dependence of the already overburdened hospital sector which is bursting at the seems – is over crowded and is grinding to a halt.

The issues as outlined above, if corrected, could and would bring significant changes to the health system, with no doubt, a reduction in the overcrowding in hospitals and the transfer of care into the more appropriate setting for some conditions.

It will not solve the trolly crisis, as these patients are those whose care is appropriate to the hospital secondary care, but if appropriate measures are taken this will result in freeing up the capacity to accommodate these patients.

Government needs to take seriously the problems that beset the health system, as to continue in the present vein can only lead to repeated failure and poorer health care for its citizens.

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